| NPI | 1740832104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062526) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 023664) |
| Enumeration Date | 2019-07-15 |
| Last Update Date | 2021-08-18 |